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Indian Journal of Anaesthesia 2008; 52 (3):264-270

Indian Journal of Anaesthesia,


June
2008
Special
Article

Paediatric Spinal Anesthesia


Rakhee Goyal1, Kavitha Jinjil2, BB Baj3, Sunil Singh4 , Santosh Kumar5

Summary
Paediatric spinal anesthesia is not only a safe alternative to general anaesthesia but often the anaesthesia
technique of choice in many lower abdominal and lower limb surgeries in children. The misconception regarding its
safety and feasibility is broken and is now found to be even more cost-effective. It is a much preferred technique
especially for the common daycase surgeries generally performed in the paediatric age group. There is no requirement of any additional expensive equipment either and this procedure can be easily performed in peripheral centers.
However, greater acceptance and experience is yet desired for this technique to become popular.
Key words

Paediatric spinal anaesthesia, Bupivacaine, Infraumbilical surgeries in children

volatile agents and muscle relaxants for general anaesthesia.

Introduction
Regional anaesthesia in children was first studied
by August Bier in 1899. Since then, spinal anaesthesia
was known to be practiced for several years with a
series of cases published as early as in 1909-1910.1-3
In 1900, Bainbridge reported a case of strangulated
hernia repair under spinal anaesthesia in an infant of
three months.4 Thereafter, Tyrell Gray, a British surgeon published a series of 200 cases of lower abdominal surgeries in infants and children under spinal anaesthesia in 1909-1910. After some years it fell into disuse because of the introduction of various muscle relaxants and inhalational agents and was almost unused
after World War II.

In the last decade, it started being advocated again


by many centers due to increasing knowledge on pharmacology, safety information and availability of specialized equipment for regional anaesthetic techniques
and monitoring in children. In the coming times, paediatric spinal anaesthesia will not only be used in cases
where general anaesthesia is risky or contraindicated
but also be the preferred choice in most lower abdominal
and lower extremity surgeries in children.

Anatomical and physiological differences


in children
There are certain features of paediatric anatomy
and physiology which are different from the adult and
thus make the central neuraxial blockade a good alternative anaesthetic technique. The spinal cord ends at
L3 level at birth and reaches L-1 by 6-12 months. The
dural sac is at the S4 level at birth and reaches S2 by
the end of the first year. The line joining the two superior iliac crests (inter-cristal line) crosses at L5-S1 interspace at birth, L5 vertebra in young children and
L3/4 interspace in adults. It is for this reason that the
lumbar puncture be done at a level below which the

Thereafter, in 1983, in the American Society of


Anesthesiologists Regional Anesthesia Breakfast Panel,
Abajian et al started the frenzy of modern paediatric
spinal anaesthesia when they reported 78 cases in 81
infants. 5 The textbook of paediatrics by Leigh and Belton
also demonstrated that 10% of all anaesthetic procedures practiced in children at the Vancouver General
Hospital were spinal techniques, including pulmonary
lobectomies and pneumonectomies.5 However, paediatric spinal anaesthesia never achieved its popularity
because of continuous discoveries of newer and better

1. Consultant, 2. Consultant, 3. Head of Department, 4. Consultant, 5.P.G.Student, Department of Anesthesiology and Critical
Care, Base hospital, New Delhi, Correspondence to: Rakhee Goyal, Department of Anesthesiology and Critical Care, Base
hospital, New Delhi, Email: rakhee_goyal@yahoo.co.in
Accepted for publication on: 18.4.08
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Rakhee Goyal et al. Paediatric spinal anaesthesia

cord ends, safest being at or below the inter cristal line.


The bones of the sacrum are not fused posteriorly in
children enabling an access to the subarachnoid space
even at this level.

critically ill and moribund neonates who present for


surgery in grave haemodynamic instability.

Pharmacology
The most important concern with the use of intrathecal local anaesthetics in infants and young children is the risk of toxicity. This age group is particularly
prone to direct toxicity to the spinal cord when administered in large doses. Neonates with immature hepatic
metabolism and decreased plasma proteins like albumin and 1 acid glycoprotein have higher serum levels of unbound amide local anaesthetics, which are normally highly protein bound (90%). A relatively higher
cardiac output and regional blood flow in infants also
increases the drug uptake from neuraxial spaces and
can predispose them to local anaesthetic toxicity besides decreasing the duration of action. Infants may have
decreased levels of plasma pseudocholinesterase which
may augment local anaesthetic toxicity especially with
the ester group.8 Various anaesthetics have been used
for paediatric spinal anaesthesia but bupivacaine and
ropivacaine remain the drugs of choice.

Another feature which is unique in infants is that


there is only one anterior concave curvature of the vertebral column at birth. The cervical lordosis begins in
the first 3 months of life with the childs ability to hold
the head upright. The lumbar lordosis starts as the child
begins to walk at the age of 6-9 months. Therefore, the
spread of isobaric local anaesthetic is different in infants particularly as compared to adults.
The subarachnoid space is incompletely divided
by the denticulate ligament laterally, and the subarachnoid septum medially. The volume of cerebrospinal fluid
CSF is 4 ml.kg-1 which is double the adult volume.
Moreover, in infants half of this volume is in the spinal
space whereas adults have only one-fourth. This significantly affects the pharmocokinetics of intrathecal
drugs. The spinal fluid hydrostatic pressure of 30-40mm
H2O in horizontal position is also much less than that in
adults.6

Indications

The neck can be in extension for lateral positioning while performing a lumbar puncture as cervical flexion is of no benefit in children and in fact, may obstruct
the airway during the procedure. It can also be performed in sitting position with the head extended.

Infraumbilical extraperitoneal surgeries like inguinal hernia, circumcision, hypospadias, orchidopexy,


cystoscopy, colostomy for imperforate anus, rectal biopsy and other perineal surgeries; lower extremity orthopaedic and reconstructive surgeries.

The physiological impact of sympathectomy is


minimal or none in smaller age groups. The fall in blood
pressure and a drop in the heart rate are practically not
seen in children less than five years. Therefore there is
no role of preloading with fluids before a subarachnoid
block. This may be due to the immature sympathetic
nervous system in children younger than fiveeight years
or a result of the relatively small intravascular volume in
the lower extremities and splanchnic system limiting
venous pooling and relatively vasodilated peripheral
blood vessels. 7 Infants respond to high thoracic spinal
anaesthesia by reflex withdrawal of vagal parasympathetic tone to the heart. It is one of the reasons why
spinal anaesthesia has been the technique of choice in

Preterm and former preterm infants less than 60


weeks post-conceptual age/less than 3 Kg/hematocrit
<30% and with other co-morbidities who are prone to
post-operative apnoea,9 bradycardia and desaturation
after general anaesthesia.
Neonates with respiratory diseases like bronchopulmonary dysplasias, hyaline membrane disease.
Children with history of or high risk for malignant
hyperthermia .
Children with acute respiratory conditions, chronic
disease of the airways like asthma or cystic fibrosis.
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Indian Journal of Anaesthesia, June 2008

Besides these common indications, there are reports of successful spinal anaesthesia in complex surgeries like meningomyelocele, gastroschisis repair, open
heart surgery 10 etc in addition to light general anaesthesia.

ever may be the drug and the route of administration, it


is important that it is customized for each type of patient and surgery involved and also safe during the entire perioperative period. 11

Procedure, needles used, drug dose

Contraindications

The basic procedure of performing a subarachnoid block in children is similar to adults and full aseptic precautions are a must. It is important to access the
CSF through appropriate space as per the age of the
child as already discussed in order to avoid trauma to
the spinal cord. Care should be taken as the child may
be asleep or inadequately sedated. However, additional
analgesia and sedation is generally required during lumbar puncture. It may be supplemented with low dose
ketamine or a short acting drug like thiopental/propofol
intravenously or inhalational anaesthetics like oxygennitrous oxide, sevoflurane or halothane during the procedure. Anticholinergic drugs may be added to decrease
any undesired secretions. Application of 5% EMLA
(eutectic mixture of local anaesthetics-lidocaine and
prilocaine) with an occlusive dressing on the appropriate and best palpated interspace about an hour before
surgery facilitates painless lumbar puncture without any
additional parenteral sedation. EMLA should be used
with caution in infants less than three months and those
receiving any methemoglobin inducing drugs like sulfonamides, phenytoin, phenobarbital, acetaminophen.12
Intraoperatively, sedation can be augmented with
midazolam upto 0.1mg.kg-1. Flavoured pacifiers for
young and music or books for older children may be
used in case the child is awake and cooperative.

Refusal of the parents, progressive neurological


disease, uncontrolled convulsions, infection of the skin
or subcutaneous tissue locally at puncture site, coagulation defects, true allergy to local anaesthetics and severe hypovolemia are some of the contraindications to
spinal anaesthesia in children.

Consent and risk-benefit aspect


Consent from the parents is an important issue
before planning a central neuraxial blockade for children. The consent should be informed and written, and
the various aspects of regional technique alongwith the
risks involved must be explained in detail. There is also
an obvious need to assess the risk involved in the procedure on an individual case basis versus the benefits
expected depending on the nature and duration of surgery, general condition of the patient and the availability of institutional care intra and postoperatively.

NPO and premedication protocols


The standard preoperative fasting guidelines are
required to be followed before elective spinal anaesthesia. 2-3 hrs fasting for clear fluids, 4 hrs for other
fluids and 6 hrs for solids is usually followed in most
centers.

The needles available for paediatric use range from


24-29 G, either short bevelled Quincke or Sprotte and
Whitacre with or without introducer with a length shorter
than that in adults. If specialised needles are unavailable or their cost is prohibitive, even hypodermic needle
or the metal stillete of a small gauge intravenous cannula can be used without much difficulty. Correct placement of the needle is ascertained by free flow of CSF.
Some of the needles also have a magnifier hub for fast
recognition of flashback of CSF. The child may be kept

Adequate premedication is the key to a smooth


regional procedure in children. Various drugs via different routes may be used to achieve a well sedated
child who allows venous puncture, placement of monitors and even a lumbar puncture. Oral combination of
ketamine 4-6mg.kg-1, midazolam 0.4mg.kg-1 and atropine 0.03mg.kg-1 is quite effective and safe in most
cases.6 Other routes of premedication like rectal, sublingual, nasal or intramuscular are also practiced. What266

Rakhee Goyal et al. Paediatric spinal anaesthesia

but the potential for toxicity with levobupivacaine is less.


Kokki et al performed a study on 40 children, aged 1
14 yr, undergoing elective lower abdominal or lower
limb surgery levobupivacaine 5 mg.mL-1 at a mean dose
of 0.3 mg.kg1 body weight, and found equivalent clinical efficacy in spinal anaesthesia in children to that of
racemic bupivacaine.14, 15

in the dependent side for a few minutes for lateralisation


of the block. A successful block usually takes about 25 mins and care should be taken that the leg is not lifted
just after the block for placement of diathermy pads
which often results in undesired cephalad spread of the
block.
The extent of the sensory block can be checked
by pin-prick or skin pinch and that of the motor block
by Bromage scale.13 This may however be difficult to
check in a deeply sedated child and can only be done
in the postanesthesia care unit (PACU) to check the
block regression. However, it can be clinically ascertained by lack of leg movement and diaphragmatic
breathing. Children very often fall asleep with the deafferentation following the block.

Ropivacaine 5mg.ml-1 has also been used in some


studies and found to be effective and safe in isobaric
form. In a study of 93 children 1-17 years of age, Kokki
H et al used 0.5mg.kg-1 (upto 20mg) in lateral decubitus position and achieved good block performance.16
Baricity is one of the most significant factors to
affect the distribution of the local anaesthetic and hence
success and spread of the blockade. The effect of differing degrees of hyperbaricity was evaluated by several workers in paediatric age group. It is not known
whether hyperbaric local anaesthetic is better than isobaric in children in contrast to adults where it is proven
to be more reliable, safe and effective.17 Isobaric
bupivacaine has also been used for spinal anaesthesia
in children and compared with its hyperbaric form.
Kokki H 18 compared bupivacaine 5 mg.ml-1, isobaric
in saline 0.9% and hyperbaric in 8% glucose, for spinal
anaesthesia in 100 children, aged 2-115 months for
paediatric day case surgery. The success rate of the
block was greater with hyperbaric bupivacaine (96%)
compared with isobaric bupivacaine (82%). Intense
motor block was associated with adequate sensory
block. Spread and duration of sensory block showed
a similar wide scatter in both groups. Cardiovascular
stability was good in both groups. The study gave an
impression of a delayed onset time of spinal block, as
most of the nine children who required either fentanyl
or a sedative for a mild reaction to skin incision had
complete block when transferred to the recovery room
after operation.

Intraoperative fluids only include deficit and maintenance amounts and preload need not be given as in
adults. The hypotensive cardiovascular response to
sympathectomy is minimal or none in children. However, standard monitoring is mandatory and oxygen by
face mask is recommended in all cases.
All patients should be monitored in the PACU for
vital signs, two-segment block regression, pain and any
other side effect. Children should only be discharged
when they are awake and able to walk unaided, the
vital signs are stable for at least 1 h, there is no pain,
nausea/retching or vomiting, and are able to tolerate
clear fluids.

Intrathecal drugs
Among the various drugs approved by FDA for
paediatric intrathecal use, 0.5% bupivacaine and
ropivacaine are common and popular. The doses used
are institutional though the standard protocol that I have
been practicing is 0.5% bupivacaine 0.1ml.kg-1 or
0.5mg.kg-1 for infants weighing 0-5 Kg; 0.08ml.Kg-1
or 0.4mg.kg-1 for 5-15Kg body weight and 0.06ml.kg1
or 0.3mg.kg-1 for >15 Kg weight.6

However, in an article published two years later


the same authors, Kokki H et al demonstrated that
bupivacaine in 0.9% glucose and in 8% glucose solutions are equally suitable for spinal anaesthesia in small

Levobupivacaine has very similar PH) armacokinetic properties to those of racemic bupiva-caine,
267

Indian Journal of Anaesthesia, June 2008

children. Similar success rate, spread and duration of


the sensory and motor block are achieved with both
baricities of bupivacaine. 19

paediatric patients and some authors have even challenged its existence. In his study on 200 children using
two different sizes spinal needles of 25 G and 29 G
Quinke, Kokki et al 21 found that 10 had PDPH with
no difference regarding the type of needle used. The
failure rate of attempted spinal anaesthesia was 4% and
even when the subarachnoid space was reached and
the local anaesthetic injected, the overall success rate
of the technique was only 91%.

Various studies have been done with child in lateral or sitting position for a subarachnoid block. In a
study on 30 preterm infants for inguinal herniotomy, Vila
et al found spinal anaesthesia to be equally effective in
both lateral and sitting position. 20
Duration is an important and a limiting factor for
paediatric spinal anaesthesia especially in infants and
younger children. Spinal anaesthesia alone for this reason is therefore generally restricted to one hour duration surgeries only. The duration is longer with larger
doses in infants and varies directly with the age of the
child. It has been seen that the duration of long acting
local anaesthetics like bupivacaine is only about 45 min
in neonates and 75-90 min in children upto five years.
There is no difference in duration by adding epinephrine to bupivacaine.

Transient neurological symptom (TNS) has been


reported by some authors following spinal anaesthesia
due to direct toxicity of large doses of local anaesthetics.
In his study on 95 patients using 0.5% isobaric
ropivacaine, Kokki et al16 reported mild to moderate
TNS in four children which was transient and was not
followed by any permanent neurological sequelae. In
another study by the same author similar results were
found with 0.5% bupivacaine.17
A one year study of 24,409 regional blocks in
children by the French-Language Society of Pediatric
Anesthesiologists, 22 the largest known study on complications, revealed a complication rate of 1.5 per 1000
in the 60% of children receiving central neuraxial blocks.
However, most of these cases were those of caudal
and some of epidural technique.

Additives
Since the duration of spinal anaesthesia does not
cover most of the postoperative period, it is essential
to add intravenous or rectal acetaminophen or
ketoprofen routinely to all patients. Profound postoperative analgesia can be achieved by adding a low dose
local anaesthetic with or without an opioid (fentanyl),
clonidine 1-2g.kg-1 or any other additive in caudal
space at the time of performing the subarachnoid block.
A caudal catheter can also be placed and local anaesthetic plus opioid added for prolonged analgesia postoperatively.

Advantages
Spinal anaesthesia produces a reliable, profound
and uniformly distributed sensory block with rapid onset and good muscle relaxation, and it results in more
complete control of cardiovascular and stress responses
than epidural or opioid anaesthesia.23 It is ideal for daycase surgeries and is safe and cost-effective. There is
no additional requirement of any special drug or equipment for the procedure. Because of these benefits, spinal anaesthesia has gained acceptance for children undergoing surgery in the lower part of the body.24

Complications
The complications related to spinal anaesthesia
are usually either due to the needle used to perform the
procedure (backache, headache, nerve or vascular injury and infection) or the drugs injected (high or total
spinal, drug toxicity). However, little data is available
regarding the incidence as compared to adults.

Comparison with general anaesthesia


General anaesthesia may be associated with several life-threatening complications especially in preterm,

Post dural puncture headache (PDPH) is rare in


268

Rakhee Goyal et al. Paediatric spinal anaesthesia

on the day of surgery and it becomes a difficult decision to cancel the surgery. Spinal anaesthesia is relatively safer in all these instances where spontaneous
airway can be maintained by the patient.

former preterm, those with co-morbidities like sepsis,


necrotising enterocolitis, anaemia (hematocrit<30%),
severe respiratory disease like respiratory distress syndrome, bronchopulmonary dysplasias, cystic fibrosis
etc. All these neonates are at much higher risk of apnoea, bradycardia and desaturation after general anaesthesia.9 Spinal anaesthesia is a safe, reliable and simple
technique in a high risk infant. In 1984, Abajian et al
sparked an interest in this group and since then all the
reports have ascertained this fact.24

Kokki et al also conducted a study on forty children, age 2-5 years undergoing paediatric surgery and
compared spinal with general anaesthesia.26 Time spent
in the operation room was shorter in the spinal anaesthesia group because the children were awake and could
immediately be transferred. The haemodynamic pattern and respiratory function were stable during spinal
anaesthesia. Arterial desaturation (< 90%), vomiting,
sore throat and micturition difficulties were the adverse
events associated with general anaesthesia. Three patients were restless after spinal anaesthesia.

In the healthy children, most of the procedures


are performed as day-case surgeries like herniotomy,
circumcision, minor urological and orthopaedic procedures. Spinal anaesthesia is a very good alternative for
such cases were the child can be returned to the family
and a lot of stress to the parents is avoided. Since less
general anaesthetic drugs including parenteral opioids
are used, the risk of postoperative respiratory depression is minimal. The stress response to surgery is also
limited and recovery is fast.

In a study of 30 cases aged 7 months to 13 years


at the Childrens National Medical Centre, Washington, open heart surgery was performed under high subarachnoid block along with light general anaesthesia by
Finkel JC et al and haemodynamic stability was found
to be maintained intra operatively in all cases.10
Spinal anaesthesia has been found to be more cost
effective as compared to general anaesthesia. The drugs
and equipment required are much less and cheaper besides the length of hospital stay which is also usually
shorter.27

Kokki et al studied 100 children for paediatric


day-case surgery and found the technique safe and effective. 18 In his 10 years of experience of paediatric
orthopaedic surgery, Bang-Vojdanovski B concluded
that spinal anaesthesia is a suitable anaesthetic technique for paediatric surgery. 25 This method of anaesthesia may avoid the increased incidence of postoperative respiratory complications associated with general anaesthesia.

Paediatric spinal anaesthesia may have been conceptualized a century ago but its golden years are yet
to come. Overall patient safety, feasibility and reliability are the key features of this technique which will only
become better with greater use, experience and research.

Intraoperative laryngo and bronchospasm are not


uncommon even in healthy infants and children besides
episodes of coughing, breath-holding, endotracheal tube
obstruction and atelectasis. Moreover, with the increasing incidence of upper respiratory infections, commonly
3-8 times in a year in paediatric age group there will
always be a risk of a hyper-reactive airway under general anaesthesia. Besides, there are no preoperative
tests feasible which would rule out any mild-moderate
respiratory infection in children. Most of the times, the
clinician has to rely only on the history provided by the
parents. More commonly the symptoms appear only

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Bainbridge WS. A report of twelve operations on infants

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